Transcript VASCULAR DISORDERS

VASCULAR STRESSORS
NR 240
Revised 2/09 JBorrero
ANATOMY & PHYSIOLOGY
ARTERIES – WALLS ARE THICKER
DUE TO GREATER SMOOTH
MUSCLE, HENCE STRONGER &
CAN WITHSTAND HIGH
PRESSURE
ANATOMY & PHYSIOLOGY
PHYSICAL PRINCIPLES THAT
DETERMINE BLOOD FLOW
1.
2.
PRESSURE CREATED BY
PUMPING OF HEART
RESISTANCE OF BLOOD
PUMPED (PVR) PERIPHERAL
VASCULAR RESISTANCE
(CHANGE IN VESSEL RADIUS)
ARTERIAL DISORDERS
SUSTAINED HIGH ARTERIAL PRESSURE
INCREASES THE EFFECTS OF INJURY AND
DISEASE
EFFECTS OF ARTERIAL DISEASE CAUSES
TISSUE ISCHEMIA  DEATH OF TISSUE
SEVERITY OF SYMPTOMS IS DEPENDENT
UPON METABOLIC RATE & TISSUE NEEDS
SURGERY MAY RE-ESTABLISH CIRCULATION
ARTERIAL ASSESSMENT
PURPOSE: TO DETERMINE
ADEQUATE TISSUE PERFUSION
GUIDE LINES
1. COMPARE UPPER & LOWER
2. COMPARE BILATERALLY
3. COMPARE DISTAL & PROXIMAL
4. SUPINE (VS) DEPENDENT
CHANGES
ARTERIAL ASSESSMENT

1.
2.
3.
MAJOR AREAS OF ASSESSMENT
CIRCULATION – PULSE MEANS
PERFUSION
MOTION – MUSCLES NEED
OXYGEN
SENSATION – PAIN, BURNING,
PROPRIOCEPTION, NUMBNESS
ARTERIAL ASSESSMENT

CIRCULATION
CHECK PULSE POINTS
CAROTID
RADIAL
FEMORAL
DORSALIS PEDIS
POSTERIOR TIBIAL
CAPILLARY REFILL
ARTERIAL ASSESSMENT
PULSES ARE BASED ON A SCALE
0 to 4+
 0 = NO PULSE
 1+ = THREADY PULSE
 2+ = NORMAL PULSE
 3+ = BOUNDING PULSE
 4+ = ANEURYSM

ARTERIAL ASSESSMENT

1.
2.
3.
4.
5.
6.
7.
ARTERIAL INSUFFICIENCY
SKIN COOL, SHINY THIN, ONION
LIKE
PAIN /W COLD
PALE /W ELEVATION
DISTAL PULSES  OR ABSENT
DECREASED OR ABSENT HAIR
ISCHEMIC ULCERS
THICK NAILS
COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
 DUPLEX ULTRASOUND
HELPS Dx NARROWING OR
OCCULUSION OF INTERNAL
CAROTIDS or DVT
FALSE (+) DUE TO
NO PATIENT PREP
CALCIFICATION
OF VESSELS
PAINLESS & SAFE
SUPINE POSITION

COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
 SEGMENTED ARTERIAL PRESSURE
MONITORING
MEASURES PRESSURE DIFFERENCE
BETWEEN EXTREMITIES AT DIFFERENT
LEVELS
USES B/P MONITOR & DOPPLER

ANKLE/BRACHIAL INDEX
EXAMPLE:
BRACHIAL PRESSURE =120mmHg
ANKLE PRESSURE = 96mmHg
ABI = 96 / 120 = 0.8
NORMAL
0.9 - 1.2
RISK IS LOW
VASCULAR
DISEASE
0.6 – 0.9
SEVERE
DISEASE
< 0.5
MODERATE
RISK EXISTS
VERY HIGH
RISK EXISTS
ARTERIAL ASSESSMENT

•
•
•
•
CLAUDICATION
INTERMITTANT CRAMPING OF
SKELETAL MUSCLES WITH EXERCISE
STANDARD – ABLE TO WALK ONE
CITY BLOCK W/O PAIN
(+) = PAIN WITH AMBULATION, PAIN
WITH ELEVATION, RELIEF WITH
DEPENDENT POSITION
Tx: pentoxyphylline (Trental)
cilostazol (Pletal)
ACUTE ARTERIAL
INSUFFICIENCY
THE 5
P’s
WHEN PRESENT = SURGICAL EMERGENCY!
PAIN
2. PALLOR
3. PULSELESSNESS
4. PARALYSIS
5. PARESTHESIA
1.
COMMON DIAGNOSTIC
VASCULAR TESTS

ANGIOGRAPHY (ANGIOGRAM)
INVASIVE TECHNIQUE – USED WHEN
SURGICAL INTERVENTION IS BEING
CONSIDERED
USED TO DIAGNOSE
EMBOLI, THROMBOSIS, TRAUMA,
ANEURYSM, BUERGER’S DISEASE,
ARTERIOSCLEROSIS
ARTERIAL DISORDERS
ARTERIAL SYSTEM PROBLEMS
CAN BE CONTROLLED BY
MODIFYING RISK FACTORS:
SMOKING
DIET
GLUCOSE CONTROL
ACTIVITY LEVEL
HYPERLIPIDEMIA
BP (DOUBLES RISK)
WHEN ARTERIES BECOME
OCCLUDED
HEALTHY ARTERIES ARE BLOOD
VESSELS WHICH ARE FLEXIBLE,
STRONG & ELASTIC
THEIR INSIDE LINING IS
SMOOTH SO BLOOD CAN FLOW
WITHOUT RESTRICTION
Risk Factors cause arteries to become
occluded.
Progression of Occlusion
PLAQUE DEPOSIT
ORIGINAL DIAMETER
ARTERIAL DISORDERS
PERIPHERAL ARTERIAL
INSUFFICIENCY / OCCLUSION
ASSESSMENT:
WEAK/ ABSENT PULSES
PAIN /W LEG ELEVATION
SKIN COOL TO TOUCH
PALE SKIN COLOR
THICKENED TOENAILS
ARTERIAL DISORDERS
GOALS:
1. IMPROVE PERIPHERAL ARTERIAL
CIRCULATION WITH EXERCISE
REGULAR EXERCISE SUCH AS
WALKING INCREASES
CIRCULATION
ARTERIAL DISORDERS
GOALS:
2. PREVENT VASCULAR COMPRESSION
AVOID RESTRICTIVE CLOTHING,
CROSSING LEGS, SITTING FOR
PROLONGED PERIODS
ARTERIAL DISORDERS
GOALS:
3. RELIEVE PAIN
CONSIDER ANALGESICS SO
PATIENT CAN PARTICIPATE IN
ACTIVITIES
ARTERIAL DISORDERS
GOALS:
4. MAINTAIN TISSUE INTEGRITY
•
•
•
•
AVOID TRAUMA, WEAR CORRECT
SHOE GEAR (NO BARE FEET!)
TEST WATER TEMP WITH HAND
NOT FOOT!
REGULAR PODIATRY CARE
GOOD NUTRITION
ANGIOPLASTY



BALLOON
ANGIOPLASTY
CATHETER
INSERTED
THROUGH AN
ARTERY
BALLOON IS
INFLATED AND
COMPRESSES
LESION
USED FOR
INSERTION OF
STENTS
ANGIOPLASTY
MEDICAL MANAGEMENT
THROMBOLYTIC THERAPY
USED TO DISSOLVE CLOTS:
Retavase, streptokinase, tPa
SURGICAL MANAGEMENT
1. GRAFTING – BYPASS SURGERY
2. ENDARTERECTOMY – REMOVAL OF
ATHEROSCLEROTIC PLAQUE
3. AORTO/FEMORAL/TIBIAL BYPASS
NURSING DX/ ARTERIAL
DISORDERS & GOALS
1.
2.
ALTERED PERIPHERAL TISSUE
PERFUSION
( ARTERIAL BLOOD FLOW)
GOAL: MAXIMIZE TISSUE PERFUSION
ACTIVITY INTOLERANCE – VASCULAR
SUPPLY CAN NOT KEEP UP WITH
TISSUE DEMANDS
GOAL: MANAGE ACTIVITY WITHIN
LIMITATIONS
NURSING DX/ ARTERIAL
DISORDERS & GOALS
3.
ANTICIPATORY GRIEVING RELATED TO
POTENTIAL LOSS OF LIMB
GOAL: EXPRESS CONCERNS
4.
BODY IMAGE DISTURBANCE AS
RELATED TO LOSS OF BODY PART
GOAL: DISCUSS IMAGE & OPTIONS
NURSING DX/ ARTERIAL
DISORDERS & GOALS
5.
6.
IMPAIRED TISSUE INTEGRITY AS
RELATED TO  CIRCULATION
GOAL: MAINTAIN TISSUE
INTEGRITY
KNOWLEDGE DEFICIT OF SELF
CARE ACTIVITIES
GOAL: EDUCATE PATIENT
NURSING DX/ ARTERIAL
DISORDERS & GOALS
7.
PAIN DUE TO ISCHEMIA
8.
GOAL: RELIEVE PAIN
POTENTIAL FOR INJURY DUE TO 
SENSATION
GOAL: EDUCATE PATIENT TO INSPECT FOR
INJURY, WATCH FOR TRAUMA
9.
SLEEP PATTERN DISTURBANCE DUE TO REST
PAIN
GOAL: MAXIMIZE SLEEP
NURSING INTERVENTIONS
1.
RISK FACTOR MODIFICATION
SMOKING (Most significant RISK FACTOR)
 NICOTINE CAUSES VASOSPASMS
WEIGHT LOSS
 REDUCES WORKLOAD IN
EXTREMITIES
LOW FAT DIET WILL RETARD
PROGRESSION OF ATHEROSCLEROSIS
CONTROL HTN
NURSING INTERVENTIONS
2.
PAIN MANAGEMENT
INTENSITY IS VARIABLE
MANAGEMENT- RTC
PAIN MEDICATION
(MAY NOT BE EFFECTIVE)
 DEPENDENT POSITION MAY 
COMFORT
NURSING INTERVENTIONS
3.
MAINTAIN FLUID VOLUME
IN SEVERE STENOSIS PATIENT MUST
MAINTAIN SUFFICIENT BLOOD PRESSURE
TO AVOID COMPLETE OCCLUSION
NURSING INTERVENTIONS
4.
ACTIVITY
 MONITOR CLAUDICATION
 TEACH PATIENT – PAIN IS NOT
HARMFUL, BUT A BODY SIGNAL
FOR NEED TO REST
 EMPHASIZE: EXERCISE INCREASES
COLLATERAL CIRCULATION
 CHECK WITH DOCTOR ABOUT ANY
EXERCISE
PROGRESSION SHOULD BE GRADUAL
NURSING INTERVENTIONS
5.
MAINTAINING TISSUE INTEGRITY
 CHANGE POSITION FREQUENTLY
 AVOID CROSSING LEGS
& CONSTRICTIVE CLOTHING
 METICULOUS FOOT CARE (PODIATRIST)
 PROTECT FROM INJURY
 KEEP EXTREMITIES WARM
(NO HEATING BLANKET OR HOT WATER
BOTTLES!)
SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY- Postop
 NEUROVASCULAR ASSESSMENT
 COMPLICATIONS
•
•
•
•

GRAFT OCCLUSION:THROMBOSIS
COMPARTMENT SYNDROME
GRAFT INFECTIONS
FISTULA/ULCER FORMATION
EDUCATE PATIENT TO
•
•
•
REPORT PAIN UNRELIEVED BY MEDS
STOP SMOKING
ID NORMAL HEALING PROCESS
SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY
 POSITIONING
KEEP LOWER EXTREMITY LEVEL
AND AVOID CONSTRICTION
• AVOID DEPENDENT POSITION
WHICH ’s EDEMA , PAIN &
HEALING
• MOBILITY IS PROGRESSIVE
•
ARTERIAL DISEASES
BUERGER’S DISEASE [TAO]
(aka: Thromboangiitis Obliterans)
1. DISEASE IS LINKED DIRECTLY TO
SMOKING (REQUIRED HX FOR DX)
2. POSSIBLE IMMUNOPATHOGENESIS
3. INFLAMMATION PRODUCES CRITICAL
LIMB ISCHEMIA
4. DISEASE CAN PROGRESS PROXIMALLY
Raynaud’s Disease
VASOSPASTIC DISORDERS:
1. BLOOD VESSELS (FINGERS & TOES) GO
INTO SPASM
2. EXTREME SENSITIVITY TO TEMP
CHANGES (ESPECIALLY COLD)
3. MORE COMMON FEMALE > MALE
4. Color changes are Red/White/Blue
RAYNAUD’S
CLASSIFIED:
1. RAYNAUD’S DISEASE = WHEN
SYMPTOMS ARE THE ONLY PRESENTING
FACTOR
2. RAYNAUD’S PHENOMENON = WHEN
SYMPTOMS ARE SECONDARY TO
ANOTHER CONDITION
EX: RA, SCLERODERMA, LUPUS, CARPAL
TUNNEL SYDROME, THORACIC OUTLET
SYNDROME
RAYNAUD’S
DX:
1. BILATERAL
2. OCCURS X 2 YEARS
3. NO OTHER CAUSE
Prevention:
1. PROTECT FROM COLD EXPOSURE
2. AVOID EXCESSIVE EMOTIONAL STRESS
3. DO NOT USE VIBRATING TOOLS
ANEURYSM
ANEURYSM = AN
LOCALIZED
ABNORMAL
DILATION OF A
BLOOD VESSEL
HIGH RISK
IN
MARFAN’S
SYNDROME
Abdominal Aortic
Aneurysm:Pathophysiology
Aneurysm-permanent localized dilation
of an artery
-enlarges to 2x normal
diameter
-middle layer of artery is
weakened
-HTN produces more tension
and enlargement within the artery
AORTIC ANEURYSMS
Location: Thoracic
Abdominal aortic aneurysms
Etiology:
Atherosclerosis (+HTN & smoking)
Syphillis
Marfan Syndrome
Ehlers-Danlos syndrome
AAA Assessment
Upper abdomen pulsation, left of
midline
 + bruit over mass
 Abdominal, flank or back pain- if
leaking or ruptured
 Abd Xray- “Eggshell Calcification”
 Cat scan
 Aortic angiography
 Ultrasonography

Interventions
Nonsurgical
 Surgical- AAA Resection
- Endovascular stent graft

Post-op care of the AAA patient:
VENOUS
ANATOMY & PHYSIOLOGY
VEINS – HAVE THIN WALLS
(LESS SMOOTH MUSCLE)
ALLOW VESSELS TO DISTEND
MORE THAN ARTERIES
Venous System
ANATOMY & PHYSIOLOGY
BLOOD FLOWS AGAINST
GRAVITY BECAUSE:
VALVES – ONE WAY VALVES
PREVENT BACKFLOW. (VALVE
COMPETENCY DEPENDS UPON
INTEGRITY OF VEIN WALL)
MUSCLE CONTRACTION MILKS
BLOOD THROUGH VESSELS
VENOUS ASSESSMENT

1.
2.
3.
4.
5.
6.
VENOUS INSUFFICIENCY
DRY, FLAKY
(BROWN & BLOTCHY)
PURPLE – DEPENDENT
ELEVATION ’s DEPENDENT EDEMA
EDEMA MAY OBLITERATE PULSES
VENOUS STASIS ULCERS
PARESTHESIAS
Disorders of Venous
Circulation


PHLEBITIS-Vein
inflammation
THROMBOPHLEBITIS
INFLAMMATION OF
WALLS OF VEINS WITH
CLOT FORMATION

PHLEBOTHROMBOSIS
CLOT DEVELOPS DUE
TO VENOUS STASIS OR
“THICK BLOOD”
HYPERCOAGUABILITY
& INFLAMMATION
DVT- Deep Vein
Thrombosis
VENOUS DISORDERS
VIRCHOW’S TRIAD
PREDISPOSING FACTORS
a)
b)
c)
VENOUS STASIS – Bedrest, BP,
HYPOVOLEMIA,
HYPERCOAGULABILITY – CANCER,SMOKING,
POLYCYTHEMIA, SURGERY, SEPSIS, OC
ENDOTHELIAL DAMAGE – STIMULATES
PLATELET AGGREGATION, VENOUS
INFLAMMATION
VENOUS DISORDERS
Other Risk Factors
d)
e)
f)
g)
h)
i)
j)
k)
IMMOBILIZATION – PARALYSIS, PROLONGED
BEDREST, LONG PLANE OR CAR RIDES
DISEASE PROCESSES – SEPSIS,
SLE,HEMATOLOGICAL DISORDERS, MS,MALIGNANCY,
CHF, MI, ULCERATIVE COLITIS
PRESSURE – OBESITY, PREGNANCY, TUMOR
TRAUMA – FRACTURES, VENIPUNCTURE
CLOTTING DYSFUNCTION
SURGICAL PROCEDURES – HIP, GYN & UROLOGICAL
& in age >40
OC use- especially in women who smoke
OTHER – DEHYDRATION, ADVANCED AGE
VENOUS DISORDERS
DEEP VENOUS THROMBOSIS (DVT)
1. PATHOPHYSIOLOGY – DEEP VEIN CLOT
MOST COMMON IN LOWER LEG (CALF)
UNDIAGNOSED DVT OCCURS IN 50% OF
PATIENTS WITH PULMONARY EMBOLI
Assessment of DVT
S&S
-Calf or groin tenderness
-Pain that can be dull or aching, especially when walking
-Sudden onset of unilateral swelling of the leg
-Cyanosis of the affected extremity
-Slightly elevated temp
-General malaise
Assessment of DVT
Homan’s Sign-pain on dorsiflexion of foot
NO LONGER ADVISED-can increase the risk of
detaching the thrombus as the calf muscle
contract
Coag studies
D Dimer-increased values with venous thrombosis,
PE, DIC and Malignancy
Duplex Scan
INTERVENTIONS
*Bedrest and leg elevation
*Warm moist soaks may be ordered
*Evaluate for PE
*Anti-inflammatory drugs for superficial
thrombophlebitis – ASA or NSAIDS
*Heparin therapy
*Warfarin (Coumadin)
Heparin Therapy
1.Prior to initiation of therapy:
Hx of bleeding disorders
CBC w/ platelet count
UA
Stool for occult blood
Creatinine level
PTT,PT, INR baseline
2. Heparin bolus is given IVP (100u/kg) followed by
continuous infusion and protocol
3. Goal is to attain aPTT level 1.5-2.5x normal
Heparin therapy
4. Assess for signs and symptoms of bleeding
5. Monitor platelet counts- can lead to heparin induced
thrombocytopenia.
6. Antidote available- protamine sulfate
Other Options:
LMWH-Longer half-life and more predictable
Lovenox- 1mg/kg Adjust for renal pts
Fragmin
Coumadin- started while pt is on heparin
-takes 3-4 days to be therapeutic
-monitor INR/PT
-antidote-Vitamin K
VENOUS DISORDERS
TREATMENT
a)
PREVENTIVE
i.
ii.
iii.
EARLY AMBULATION
EXTERNAL COMPRESSION (VCB)
PROPHYLACTIC ANTICOAGULANTS
LOW DOSE HEPARIN
LOW MOLECULAR WT. HEPARIN (FRAGMIN©)
b)
WHEN DVT EXISTS
i.
ii.
iii.
BR TO CHANCE OF EMBOLI
ELEVATION TO  VENOUS RETURN &  EDEMA
ANTICOAGULANTS PREVENT CLOTS FROM
INCREASING (THEY DO NOT DISSOLVE THEM!)
VENOUS DISORDERS
AMBULATION – PERMITTED WHEN EDEMA .
BELOW KNEE TEDS USED IF NO ARTERIAL
DISEASE
(TEDS MAY INTERFERE WITH ARTERIAL FLOW)
THROMBECTOMY – SURGICAL TREATMENT OF
CHOICE WHEN ARTERIAL FLOW IS AFFECTED
BY DVT
(GREENFIELD FILTER PREVENTS “SHOWER” OF
PULMONARY EMBOLI) INSERTED IN INFERIOR
VENA CAVA
GREENFIELD FILTER


Inserted into
Inferior Vena
Cava
Filters out clots
as blood returns
to the right side
of the heart
GREENFIELD FILTER

READILY
IDENTIFIED ON
X-RAY
VENOUS DISORDERS
Health Teaching
Safety and comfort measures
Balance rest and activity
Need for follow up
Importance of taking drugs and not missing doses
Medi-alert bracelet
Avoid OTC meds
Avoid hi fat and hi Vitamin K foods- cabbage,
cauliflower,broccoli, asparagus, spinach, kale, fish and
liver
Patient teaching re: LMWH injections
CHRONIC VENOUS
INSUFFICIENCY
1.
PATHOPHYSIOLOGY & EPIDEMIOLOGY
•
OCCURS IN 10% OF POPULATION /W DVT
•
Stasis of blood in lower extremity-due to
prolonged standing, sitting in one position,
pregnancy, and obesity
•
INCOMPETENT VALVES IN DEEP VEINS
•
 VENOUS PRESSURE IMPEDES CAPILLARY
PERFUSION
•
PROTEINS LEAK INTO INTERSTITIAL TISSUES
•
EDEMA IS CHRONIC  ULCERS & SCARRING
CHRONIC VENOUS INSUFFICIENCY
Venous Stasis Ulcers
SIGNS & SYMPTOMS – INDURATION 
HYPERPIGMENTATION, STASIS DERMATITIS &
ULCERATIONS, EDEMA
GOALS: Decrease edema and Promote venous return
INTERVENTIONS:
2.
3.
4.
a)
b)
c)
d)
e)
f)
g)
COMPRESSION – STOCKINGS OR DRESSINGS
ULCERS TREATED WITH TOPICAL AGENTS-Unna,Accuzyme
AVOID TRAUMA
AVOID SITTING FOR LONG PERIODS
EXERCISE TO  MUSCLE ACTIVITY
Platelet derivative growth factor ointments-Regranex
Apligraf-type of skin graft
Varicose Veins

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



Protruding veins that are
darkened/tortuous are caused by weak
vein walls, increased venous pressure &
incompetent valves
Common in patients that stand for long
periods
Pregnancy
Obesity
Family hx of varicose veins
Systemic problems-heart disease
Assessment- S & O Data







Severe, aching pain in leg
Leg fatigue and heaviness
Itching over the affected leg (statis
dermatitis)
Feelings of heat in the leg
Visibly dilated veins
Thin, discolored skin above the ankles
Increased incidence of PE and
thrombophlebitis
Diagnostic Tests
Tourniquet test
 Trendelenberg test
 Doppler ultrasound/ angiography

Medical and Surgical Interventions
for Varicose Veins



Elevate extremity
Elastic Stockings
Sclerotherapy-for
small/limited # of
veins
Vein stripping or
ligation
EndoVenous Laser
tx
RF (radio
frequency)
-vein is heated from
inside
Nursing Interventions
Monitor patient postop
 Assess circulation
 Elevate legs and perform active ROM
 Teach re: avoidance of venous stasis,
compression stockings, exercise, leg
elevation

Lymphatic System
ANATOMY & PHYSIOLOGY
LYMPHATIC SYSTEM – WORKS WITH
CIRCULATORY SYSTEM
a)
b)
THORACIC DUCT
b
RIGHT LYMPHATIC DUCT
DRAINAGE:
THORACIC DRAINS ABDOMEN
(R) DRAINS HEAD, NECK & THORAX
a
ANATOMY & PHYSIOLOGY
LYMPHATIC FLUID COLLECTS &
RETURNS TO VENOUS CIRCULATION BY
EMPTYING INTO SUBCLAVIAN VEINS
WHEN INTERSTITIAL FLUID PRESSURE
INCREASES LYMPHATIC FLOW
INCREASES
WHEN DRAINAGE IS IMPAIRED EDEMA
ENSUES (FLUID COLLECTS)
ANATOMY & PHYSIOLOGY

CAUSES OF LYMPHEDEMA INCLUDE:
LYMPHANGITIS
CELLULITIS
INSUFFICIENT NUMBER OF VESSELS
SECONDARY FACTORS
MALIGNANCY
TRAUMA
SURGICAL REMOVAL
Assessment








Pain at site of injury
Redness of skin
Fever and chills
Red streak on skin extending toward the
lymph nodes
Lymph nodes enlarged
WBC, Blood & Wound cultures
Lymphangiography-IV dye, Xrays
Lymphoscintigraphy-simple,no SE
INTERVENTIONS







Moist heat
Elevation and immobilization of the extremity
Elastic stockings
Na restriction
Antibiotics/antifungals for infection
Diuretics
Analgesics
CASE STUDY
MR. CHARLES HORSE WAS ADMITTED
TO THE HOSPITAL TODAY WHERE HE
PRESENTED HIS CHIEF COMPLAINTS
AND RECENT MEDICAL HISTORY.
THIS PATIENT IS A FIFTY-THREE YEAR
OLD WHITE MALE. MR. HORSE IS A
RUGGED INDIVIDUAL WITH AN
EXTENSIVE HISTORY.
HE SMOKES 1 PACK OF CIGARETTES PER
DAY FOR MORE THAN TWENTY
FIVE YEARS. AS A SINGLE LUMBERJACK HIS
DIET HAS RELIED HEAVILY ON FAST FOODS.
OVER THE PAST SEVERAL MONTHS MR.
HORSE REPORTED HE HAD GRADUALLY
BEEN EXPERIENCING PAIN IN THE LEFT LEG.
THESE PAINFUL SYMPTOMS INCREASED TO A
POINT WHERE HE CANNOT WALK MORE THAN
TWO CITY BLOCKS WITHOUT SEVERE
CRAMPING IN HIS LEFT LEG.
HE STATES HE MUST STOP, SIT AND
RUB HIS LEG UNTIL THE CRAMPING
STOPS. MR. HORSE HAS GRADUALLY
ADJUSTED HIS ACTIVITIES AROUND
THESE SYMPTOMS.
THIS MORNING, MR. HORSE AWOKE
FROM A DEEP SLEEP TO SUDDEN,
SEVERE PAIN IN THE LEFT LEG. THE
PAIN DIMINISHED SLIGHTLY WHEN HE
SAT UP AND HUNG HIS LEGS OVER
THE SIDE OF THE BED.
HE NOTICED CHANGES IN SKIN COLOR
AND TEMPERATURE. CONCERNED
ABOUT THE SUDDEN CHANGES, MR.
HORSE HEADED DIRECTLY TO THE
EMERGENCY ROOM.
WHEN YOU ASSESS THIS PATIENT
ATTENTION IS DIRECTED TOWARD HIS
LEFT LEG. THE SKIN IS COOL TO
TOUCH. ASSESSING PERIPHERAL
PULSES YOU NOTE THAT HIS
FEMORAL AND POPLITEAL PULSES
ARE STRONG AND PALPABLE
BILATERALLY.
HOWEVER, HIS POSTERIOR TIBIAL AND
DORSALIS PEDIS PULSES ON THE LEFT
LEG ARE NOT PALPABLE. A DOPPLER
READING INDICATES THERE IS SOME
DEGREE OF CIRCULATION PRESENT.
NAIL BEDS ARE CYANOTIC; CAPILLARY
FILLING IS SLOW (> 3 SECONDS) IN ALL
DIGITS ON THE LEFT FOOT.
ATTEMPTING TO IMPROVE MR.
HORSE’S COMFORT, THE NURSE
ELEVATES HIS FEET. MR. HORSE
REPORTS THE PAIN IS SIGNIFICANTLY
WORSE!
LEFT LEG DISCUSSION
1. WHAT INFORMATION DOES
INSPECTION OF THE PATIENT’S LEG
PROVIDE?
PALE
a) COLOR OF SKIN
b) COLOR OF NAIL BEDS
CYANOTIC
2. WHAT CAN PALPATION TELL YOU
ABOUT THIS PATIENT’S CONDITION?
a) TEMPERATURE
COOL TO TOUCH INDICATES  BLOOD
FLOW,  SENSITIVITY
b) PULSES
 BLOOD FLOW, WEAK PULSES
(+) FEMORAL, (+) POPLITEAL PULSES
CHECK FLOW WITH DOPPLER
3. WHAT POSITION WOULD BE THE MOST
COMFORTABLE FOR MR. HORSE?
SUPINE OR DANGLE
4. WHAT PROBLEM DO YOU THINK MR.
HORSE HAS WITH HIS LEFT LEG?
ARTERIAL INSUFFICIENCY
5. WHAT WOULD PREDISPOSE MR. HORSE TO
DEVELOPING THIS TYPE OF PROBLEM?
SMOKING,  LIPIDS, PROBABLY CAD,
POSSIBLE DAMAGE TO INTIMAL LAYER
OF BLOOD VESSELS
6. WHAT IS THE CLINICAL TERM FOR A
CONDITION CAUSING PERIODIC CRAMPING
BROUGH ON BY WALKING?
INTERMITTANT CLAUDICATION
7. WHAT ARE THE 5 P’s YOU SHOULD
LOOK FOR?
PAIN
PALLOR
PULSELESSNESS
PARALYSIS
PARESTHESIA
THIS IS A
SURGICAL
EMERGENCY!
FOLLOWING A SUCCESSFUL
REVASCULARIZATION PROCEDURE,
MR. HORSE WAS D/C’d TO HOME IN
GOOD CONDITION. HIS LEFT LEG
WAS WARM, PINK IN COLOR AND ALL
TOES WERE MOBILE. MR. HORSE
WAS PLACED ON MEDICATIONS TO
MANAGE HIS CHF, WHICH WAS
DISCOVERED DURING IHIS MEDICAL
HISTORY AND PHYSICAL EXAM. TWO
WEEKS LATER THIS PATIENT
RETURNED TO THE HOSPITAL…
PRESENTING WITH DYSPNEA,
ORTHOPNEA AND BILATERAL +3
PITTING EDEMA. MR. HORSE WAS
READMITTED TO THE HOSPITAL WITH
A DX OF CHF. DIGOXIN (A
CARDIOTONIC) WAS STARTED AND
LASIX (A DIURETIC) ALSO WAS ADDED
TO HIS MEDICATION PROFILE. ONCE
AGAIN MR. HORSE WAS D/C’d TO
HOME AND PROVIDED WITH A HOME
HEALTH AIDE TO ASSIST HIM WITH HIS
ADL’s. HE WAS INSTRUCTED TO
REMAIN ON BED REST
FOR ONE WEEK. HE IS SEEN BY THE
VISITNING NURSE IN HIS HOME ON F/U
TO ASSESS HIS STATUS. THE NURSE
TAKES NOTICE OF MR. HORSE’S +2
PITTING EDEMA IN HIS RIGHT LEG,
EXTENDING FROM THE FOOT TO THE
LOWER THIGH. SKIN COLOR IS
NOTED TO HAVE A REDDISH/ PURPLE
HUE AND THE SURFACE TEMP IS
INCREASED LOCALLY. THE LIMB IS
TENDER TO TOUCH AND PAIN
INCREASES WITH DORSIFLEXION.
THE NURSE ALSO NOTES THAT
PERIPHERAL PULSES ARE
MODERATELY DIMINISHED ON THE
RIGHT SIDE ONLY. MR. HORSE
COMPLAINS THAT HIS RIGHT LEG
FEELS HEAVY AND THROBS.
RIGHT LEG DISCUSSION
1. WHAT DOES INSPECTION OF HIS
RIGHT LEG REVEAL?
a) SKIN COLOR
DUSKY RED
b) GIRTH / TENSION
(+) SWELLING
2. WHAT DOES PALPATION TELL YOU
ABOUT THE STATUS OF HIS RIGHT
LEG?
a) TEMPERATURE
 TEMP INDICATES INFLAMMATION
b) EDEMA
(2+) PITTING EDEMA, VENOUS CONGESTION
3. WHAT DO YOU THINK THE PROBLEM
IS WITH MR. HORSE’S RIGHT LEG?
(+) DVT
4. WHAT DO YOU THINK CAUSED MR.
HORSE’S RECENT COMPLICATIONS?
PROLONGED BED REST DUE TO CHF,
INACTIVITY, DEHYDRATION FROM LASIX, 
BLOOD VISCOSITY
5. HOW COULD THESE PROBLEMS
HAVE BEEN AVOIDED?
LMWH, VCB, EXERCISE
BONUS QUESTION
LIST EXAMPLES THAT PREDISPOSE A
PATIENT TO DVT
FACTORS
EXAMPLE
IMMOBILIZATION
OPERATING ROOM > 2 HOURS
PARALYSIS
DISEASE PROCESS
CARDIAC
DIABETES MELLITUS
LOWER EXTREMITY EDEMA
SEPTICEMIA
CANCER
PRESSURE
CAST / BRACES
TRACTION
CLOTTING DYSFUNCTION
POLYCYTHEMIA
SHORT CLOTTING TIME
FACTORS
EXAMPLE
SURGICAL PROCEDURES
GYNECOLOGICAL
GENITOURINARY
ANY ABDOMINAL SURGERY
LOWER EXTREMITY FRACTURE
OTHER
OBESITY
PREGNANCY
TRAUMA
TRAUMA TO A VESSEL
NCLEX TIME
Which of the following clients should the nurse assess first?
• A.The 76-year-old woman who has had laser-assisted
angioplasty of the right distal femoral artery 30 minutes
ago
• B.The 65-year-old man with a history of hypertensive
crisis who is on a labetalol drip and current blood
pressure is 149/80
• C.The 60-year-old woman with a history of peripheral
vascular disease who has a venous leg ulcer draining
purulent yellow fluid
• D.The 55-year-old man with a history of axillofemoral
bypass 5 years earlier who is currently admitted for a
diagnostic cardiac catheterization
NCLEX TIME
Which of the following statements indicates the caregiver
does not understand proper care of the client with
peripheral arterial disease of the lower legs?
• A.“The client should drink fluids to decrease risk for
viscous blood.”
• B.“We must remind the client to refrain from wearing
restrictive clothing.”
• C.“The client should apply heat directly to the legs in
order to promote blood circulation.”
• D.“The client should be encouraged to stop smoking
because it increases the vasoconstriction of the arteries.”
NCLEX TIME
You are caring for a 75-year-old man admitted to the
hospital for lower leg cellulitis. On admission, the nurse
notes that his blood pressure is 190/100 and notifies the
physician. Of the following orders, which would you have
the LPN implement?
A.Assess cardiac and respiratory status.
B.Administer Clonidine patch for hypertension.
C.Obtain an order from the doctor for dietary consult.
D.Develop plan for discharge and assess homecare needs.
NCLEX TIME
A group of new graduate nurses is in orientation to work on
a cardiothoracic stepdown unit. Which statement, if
made by one of the nurses, demonstrates the need for
further teaching regarding the difference between
arteriosclerosis and atherosclerosis?
• A.“Arteriosclerosis is a thickening, or hardening, of the
arterial wall.”
• B.“Atherosclerosis is a type of arteriosclerosis that
involves the formation of plaque within the arterial wall
and is the leading contributor to coronary artery and
cerebrovascular disease.”
• C.“Atherosclerosis is caused by vascular damage.”
• D.“Arteriosclerosis happens when platelets aggregate
and then a group of blood lipids accumulate.”
NCLEX TIME
Because Mr. Palan's condition has progressed to severe
rest pain that is now threatening loss of his limb, an
arterial revascularization has to be performed. Which
statement, if made by Mr. Palan, demonstrates that
further teaching is needed related to his postoperative
care?
A.“I should be concerned if my foot turns blue.”
B.“I should not get a fever or any drainage after the
surgery.”
C.“I may get a feeling of tenseness after the surgery.”
D.“Warmth, redness, and swelling are expected after
surgery.”
NCLEX TIME
5.Clara is teaching a young woman ways to
prevent venous thromboembolism during
hospitalization. Which statement, if made by the
client, indicates the need for further teaching?
• A.“I need to stop taking my birth control pill.”
• B.“I should drink a lot of water so I don't get
dehydrated.”
• C.“I should exercise my legs when I have been
sitting or standing for a long time.”
• D.“If I wear pantyhose, I don't have to wear the
stockings that the hospital gives me.”